Provider Demographics
NPI:1689882524
Name:GREEN, MELODY D (MA)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:D
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:MELODY
Other - Middle Name:D
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:111 RACINE ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-2707
Mailing Address - Country:US
Mailing Address - Phone:901-323-3600
Mailing Address - Fax:901-323-3640
Practice Address - Street 1:3251 POPLAR AVE STE 230
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-3631
Practice Address - Country:US
Practice Address - Phone:901-327-6650
Practice Address - Fax:901-327-6162
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN708106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist